Monday, January 14, 2013

Proposed New NYC Medical Payments

Another possible headline: "Government bureaucrats and doctors' union negotiate over pay incentives to reward/punish doctors for practicing a certain way in NYC public hospitals".

Welcome to the future.

In
principle, paying for performance is fine. But when metrics are chosen
badly (or because they're easy to measure even when they have little
bearing on actual quality of care), then you're setting the stage for
all manner of unintended consequences.

One
example are rules to pay/not-pay based on whether patients develop a
certain type of catheter-related urine infection. These rules have
resulted in switching to different protocols that reduce that particular type of
infection, but can cause more patient pain (which isn't measured) and
elevates the risk of different kinds of bladder infection and/or injury.

Of
course, this isn't a problem limited to medicine. Nor is it solely a
problem of government (vs. badly run private bureaucratic organizations).
But far too many of the proposed "quality
measures" I've seen are the equivalent of "security theater".Yes, I've
definitely seen many cases of quackery and bad medical practice. But the
response by too many policy-makers has been to advocate purportedly "objective" or "evidence based" protocols, which many doctors criticize as being too rigid or
"cookbook medicine". Bad doctors can
inappropriately use their medical autonomy unwisely. But the solution
is not blunt tools that reduce medical autonomy across the board.

On a personal note, my wife Diana
has some thyroid problems and she's an outlier on how she responds to
certain treatments. If she were treated according to the standard
protocols, she'd be in constant misery. Fortunately, she was able to
find a physician specializing in her type of problem and is willing to
judiciously stray outside the standard guidelines. As a result, she has
done well.

But
in many of the new payment models, this treatment course would be
presumed to be bad medicine, even though it is completely appropriate
for the small but non-trivial segment of the population that doesn't
respond well to the standard therapy.There's
room for constructive debate on incentive structures and their effect on medical
quality. I've practiced in academia (as a salaried university medical
school professor), in a large HMO (Health Maintenance Organization)
where doctors were paid on a "capitated" basis, and in traditional
fee-for-service private practice. All of those systems have pluses and
minuses, and all of those systems can create good incentives as well as
perverse incentives to "game" the system.My
big concern is that proposed payment "reforms" will not accomplish its stated goals, but will create far more unintended consequences than its proponents realize.

About FIRM

America was founded on the principles of freedom and individual rights. Applied to medicine, the law must respect the individual rights of doctors and other providers, allowing them the freedom to practice medicine. This includes the right to choose their patients, to determine the best treatment for their patients, and to bill their patients accordingly. In the same manner, the law must respect the individual rights of patients, allowing them the freedom to seek out the best doctors and treatment they can afford.

Freedom and Individual Rights in Medicine (FIRM) promotes the philosophy of individual rights, personal responsibility, and free market economics in health care. FIRM holds that the only moral and practical way to obtain medical care is that of individuals choosing and paying for their own medical care in a capitalist free market. Federal and state regulations and entitlements, we maintain, are the two most important factors in driving up medical costs. They have created the crisis we face today.

Freedom and Individual Rights in Medicine was founded by Lin Zinser and Paul Hsieh, MD in 2007. It is now managed by Paul Hsieh, MD.